Laserfiche WebLink
SERVICE REQUE EH0061SR revised 0711018 <br /> Type of Business or Property FACILITY ID U S VICE R Q <br /> GAS 'b�� tori . ( <br /> OWNER I OPERATOR .�� a BILLING PARTY u <br /> FACILITY NAME .�., <br /> TEA &6- Ft L-0 <br /> SITE ADDRESS <br /> 57` GeAt��c.iic, Q <br /> ' dm6d Direction <br /> IVe Suite 0 <br /> Street N <br /> Mailing Address (If Different from Site Address) <br /> CITY I C STATE CA ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# / <br /> PHONE#2 ET- BOS DISTRICT LOCATION CODE <br /> a - 33 `G M 7 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PONE# EXT. <br /> C l l-:. �� iii i 'ice t,:_. o �c3 7—76 00 <br /> MAILING ADDRESS ILI FAX# ,� / <br /> �. , <br /> 7- 1 <br /> CITY 0 0[—S I STATE _V_ ZIP 9 J J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/Or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I nl�n rrrtify Ihaf I hav# per red this applic lion and that the work to be performed will be done in accordance with all SAN JOAQUIN GCI't Tr <br /> Ordinance Codes, Standni IATE and F[Dt ; L laws. Q <br /> APPLICANT SIGNATURE: MC DATE: <br /> PROPERTY/BUSINESS OWNE OP R/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the Sam time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> T -TAYTA1k ck 4 --tom 0"S. i= Atli 14;0-oi' Zr 64J pLS2r-J;iAS <br /> C m NTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHERL'/v U <br /> ❑ <br /> j <br /> V <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'a SIGNARE: /j/ j D E: <br /> X; <br /> APPROVED BY: EMPLOYEE#: > -� DATE: 2� �� <br /> ASSIGNED TO: -(ri1 , ��_ EMPLOYEE#: 6q z�- ( DATE: <br /> Date Service Completed (if already completed): SERWE CODE: n P I E: 2— <br /> Fee <br /> Fee Amount: e �D Amount Paid Payment Date <br /> Payment Type Invoice# Check# (� Received By: <br />